# NTSB ERA09LA201: Piper PA-28-161, N613FT, Sanford, FL, March 17, 2009 - Type: NTSB accident investigation - Classification: Accident · No injuries · Limited investigation · Final report - Date: March 16, 2009, 21:30 local (Mar 17, 2009, 01:30 UTC) - Place: Sanford, FL - Coordinates: 28.776666, -81.235557 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=28.7767&lon=-81.2356&mi=10 - Phase of flight: [Standing](https://openairdocs.org/ntsb-phases/150) (OpenAirDocs' grouping) - Defining event: [Standing-engine(s) not oper: Fire/smoke (non-impact)](https://openairdocs.org/ntsb-events/150) - Highest injury: No injuries - Injuries: 2 uninjured - Status: Completed, report October 19, 2009 - Report: Approved by Office Director - NTSB office: Eastern Region Aviation - Parties: FAA/FSDO - NTSB case key (mKey): 73501 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=ERA09LA201 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/73501/pdf - NTSB docket: https://data.ntsb.gov/Docket?ProjectID=73501 - Page: https://openairdocs.org/ntsb/ERA09LA201 ## Probable cause An engine air induction explosion for an undetermined reason during repeated engine start attempts. ## Findings NTSB's coded findings; those marked are part of the probable cause. - [Not determined](https://openairdocs.org/ntsb-findings/05000000): Not determined › Not determined · Unknown/Not determined (probable cause); cases with it: [Piper PA-28-161, 14 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md?model=7102803), [All aircraft, 2,247 cases](https://openairdocs.org/ntsb-findings/05000000/cases.md) ## Sequence of events The events NTSB coded, in order, by phase of flight. The defining event best describes what happened. - [Landing-landing roll: Loss of engine power (total)](https://openairdocs.org/ntsb-events/341); cases with it: [Piper PA-28-161, 22 cases](https://openairdocs.org/ntsb-events/341/sequence.md?model=7102803), [All aircraft, 3,820 cases](https://openairdocs.org/ntsb-events/341/sequence.md) - [Standing-engine(s) not oper: Fire/smoke (non-impact)](https://openairdocs.org/ntsb-events/150) (defining event); cases with it: [Piper PA-28-161, 9 cases](https://openairdocs.org/ntsb-events/150/sequence.md?model=7102803), [All aircraft, 504 cases](https://openairdocs.org/ntsb-events/150/sequence.md) ## Analysis The student pilot was making a stop-and-go landing and used maximum wheel and aerodynamic braking to stop the airplane. After coming to a stop, both pilots realized that the engine had stopped running. After calling tower personnel and advising them of the situation, the instructor attempted to re-start the engine. Four total re-start attempts were made. After the fourth attempt, the pilots noticed smoke and flames coming from the engine compartment. The instructor moved the mixture control to idle cut-off, and exited the airplane. A Federal Aviation Administration inspector examined the airplane and reported fire damage to the engine and airframe, including firewall deformation. The inspector stated that the fire appeared to originate in the induction system air box. In addition, damage to the air box was consistent with a fuel-air explosion. During the course of the investigation the source of the original loss of power was not identified, nor was it definitively proven how the air box was damaged; however, flooding of the engine during repeated attempts to start the engine could have played a role in the accident. The operator's maintenance personnel reported that the airplane did not have a history of engine problems. ## Factual narrative On March 16, 2009, about 2130 eastern daylight time, a Piper PA-28-161, N613FT, was substantially damaged following an engine fire on the runway at the Orlando Sanford International Airport (SFB), Sanford, Florida. The airplane was registered to FIT Aviation LLC and operated by the Florida Institute of Technology. The commercial-rated flight instructor and one student were not injured. Night, visual meteorological conditions prevailed at the time, and a visual flight rules flight plan was filed for the 14 Code of Federal Regulations Part 91 flight. The flight originated at Melbourne, Florida (MLB) about 2015. The student pilot requested a stop-and-go landing and the flight was subsequently cleared for the option on runway 27R at SFB. The student used maximum wheel and aerodynamic braking to stop the airplane. After coming to a stop on the runway, the engine quit. The pilots contacted the tower to inform them of the situation. Four restart attempts were made by the instructor, with about 20 seconds allowed between attempts. After the last attempt, thick smoke was observed coming from the engine cowling. Flames were observed coming from the engine, and the instructor cut the fuel mixture to idle, took the fire extinguisher, and both pilots exited the airplane. The instructor attempted to put out the fire; however the halon extinguisher was inoperative. The pilots reported that there was a steady stream of fuel pouring out from under the engine cowling. The instructor reported that the incident may have been prevented by not attempting a fourth start attempt and having the airplane towed off the runway. An inspector from the Federal Aviation Administration examined the airplane and reported that there was extensive fire damage near the underside of the engine in the area of the induction system and carburetor. The firewall showed indications of heat deformation. Further examination revealed that the induction system air box appeared to be "blown apart from the inside out…" The inspector stated that the fire "appeared to have started near the air box on the bottom left of the engine and ignited the fuel that had over flowed into the air box." The certificated flight instructor held a commercial pilot certificate with airplane single- and multi-engine land ratings. The student pilot held a student pilot certificate and was enrolled in the private pilot certificate program at the Florida Institute of Technology. The airplane received an annual inspection on December 18, 2008. Total airframe time 14,512 hours and total time on the engine was 6,168 hours. The operator’s maintenance personnel reported that there were no recent problems with the airframe or engine. The 2245 EDT weather observation for SFB included the following: surface winds from 310 degrees at 6 knots, 10 statute miles visibility, clear skies, temperature 72 degrees Fahrenheit, dew point 59 degrees Fahrenheit, and an altimeter setting of 30.14 inches of mercury. The PA-28-161 Pilot'sInformation Manual addresses procedures for engine fire during start. Section 3, Emergency Procedures, section 3.7, states, "Engine fires during start are usually the result of overpriming. The first effort to extinguish the fire is to attempt an engine start in order to draw the excess fuel back into the induction system. If a fire is present before the engine has started, try to draw the fire back into the engine by moving the mixture control to idle cut-off, opening the throttle, turning OFF the electric fuel pump and fuel selector, while cranking the engine." ## Aircraft - Registration: [N613FT](https://openairdocs.org/deregistered/N613FT-2009-05-11), registration cancelled 2009-05-11, S/N 2841236, built 1989 (OpenAirDocs) - Reported make and model: PIPER PA-28-161 - Registry model: [Piper PA-28-161](https://openairdocs.org/model/piper-pa-28-161) (registry code 7102803) (OpenAirDocs) - Registry engine: [Lycoming 0-320 series](https://openairdocs.org/engine/lycoming-0-320-series) (registry code 41508, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 2841236 - Airframe hours: 14512 - Engines: LYCOMING O-320-D3G 160 horsepower reciprocating - Damage: Substantial damage - Fire: On-Ground - Flight: Instructional, Part 91 - Operator: Florida Institute of Technology - Registered owner: F I T Aviation LLC - Airworthiness certificate: Standard, Utility; Standard, Normal - Last inspection: 100 hour, December 18, 2008, 80 hours before - Departed: MLB, Melbourne, FL - Destination: SFB, Sanford, FL - Flight plan: VFR - Airport: SFB, Orlando Sanford International, runway 27R, 9,600 × 150 ft, asphalt ## Flight crew As NTSB recorded them. NTSB leaves out names. - Flight instructor; age 24; injuries: none; flight instructor, commercial; airplane ratings: single-engine land, multi-engine land; instrument ratings: airplane; medical: class 1, without waivers/limitations; last flight review November 19, 2008; seat: right; flight hours: 1,068 total, 803 in this make and model, 992 as pilot in command, 158 in the last 90 days, 75 in the last 30 days, 3 in the last 24 hours - Student pilot; age 25; injuries: none; student; medical: class 3, without waivers/limitations; seat: left; flight hours: 38 total, 38 in this make and model, 2 as pilot in command, 38 in the last 90 days, 24 in the last 30 days ## Weather - Conditions: Visual (VMC), Night - Wind: 310° at 6 knots - Visibility: 10 statute miles - Lowest ceiling: none - Temperature: 72 °F, dew point 59 °F - Altimeter: 30.13 inHg - Observed at: SFB ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 20090316003979A](https://openairdocs.org/incident/20090316003979A), Mar 16, 2009: Piper PA28161, Orlando, FL, Substantial damage. (-23) The aircraft experienced a complete loss of engine power after landing on runway 27R, at ksfb, in Sanford, Florida. The pilot tried to restart the… ## Docket (6 files) The files NTSB released with the investigation on August 21, 2009, on NTSB's docket system: https://data.ntsb.gov/Docket?ProjectID=73501. 4.0 MB in all. - Pilot/Operator Aircraft Accident Report, NTSB Form 6120.1 (item 1, .PDF, 842 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40313702&FileExtension=.PDF&FileName=Pilot%2FOperator%20Aircraft%20Accident%20Report,%20NTSB%20Form%206120.1-Redacted.PDF - Reports from Federal Agencies - FAA Inspector Statement (item 2, .PDF, 14 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40313703&FileExtension=.PDF&FileName=Reports%20from%20Federal%20Agencies%20-%20FAA%20Inspector%20Statement-Master.PDF - Miscellaneous - Excerpts from Piper PA-28-161 PIM (item 3, .PDF, 756 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40314574&FileExtension=.PDF&FileName=Miscellaneous%20-%20Excerpts%20from%20Piper%20PA-28-161%20PIM-Master.PDF - Photo 1: N613FT, Frontal View (FAA Digital Photo) (item 4, .PDF, 216 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40314577&FileExtension=.PDF&FileName=Photo%201%3A%20N613FT,%20Frontal%20View%20(FAA%20Digital%20Photo)-Master.PDF - Photo 2: N613FT, Side View (FAA Digital Photo) (item 5, .PDF, 183 KB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40314581&FileExtension=.PDF&FileName=Photo%202%3A%20N613FT,%20Side%20View%20(FAA%20Digital%20Photo)-Master.PDF - Photo 3: Induction Airbox (FIT Aviation Digital Photo) (item 6, .PDF, 2.0 MB): https://data.ntsb.gov/Docket/Document/docBLOB?ID=40314584&FileExtension=.PDF&FileName=Photo%203%3A%20Induction%20Airbox%20(FIT%20Aviation%20Digital%20Photo)-Master.PDF From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.